Distress Behavior Conversations: Supporting Whole Person Whole Team Responses in VA Community Living Centers

Abstract Resident distress behavior, a prevalent challenge in long-term care, contributes to resident morbidity, staff burden, and turnover. We describe an education model developed in the Veterans Administration (VA) Community Living Centers (CLC) through a CONCERT (VA CLCs’ Ongoing Center for Enhancing Resources & Training) quality improvement series. The Distress Behavior Conversation (DBC) uses a team meeting structure and process. Informed by unmet need and relational coordination theories, it guides the whole team, inclusive of interdisciplinary team members and front-line staff with resident contact, through a collaborative problem-solving action-planning discussion. DBC uses facilitated round-robins to identify potential resident behavior causes and individualized solutions. DBC supports the team in maintaining whole person and whole team mindsets, thus challenging the narrower medical model of discipline-specific clinical mindsets and staff level hierarchies. Over two years we have co-created and refined DBC through trainings and team debriefings with over 80 CLCs. Care teams reported “aha” moments during DBCs their thinking shifted (“we are now looking at the REAL why”; “we went from asking, how did he fall? to, why did he fall?; “tended to try to treat falls in a standardized way, [but] when you focus on a specific person you get to focus on HIS needs”; “personal information about the Veteran is the 5th vital sign!”). Teams additionally reported reduced strain and improved collaborative thinking (“I feel better about what I’m doing...more motivated to keep going!; “Now I see it is a team approach – don’t have to do it by myself.”).

Seven CCs were recruited and four received the DCPR overview and self-assessment. Of the four CC, one withdrew and did not receive the intervention. The remaining three were located in a suburban area, nonprofit, and with memory care units. Data was collected from November 2019 through March 2020. Nine CC staff participated with a mean age 35.8 years and had worked for 11.8 years. Baseline mean scores on the Organizational Readiness to Implementing Change (ORIC) scale were 4.6 for the commitment domain and 4.4 for the efficacy domain. Mean scores on the Nursing Home Employee Satisfaction Survey were high. Sixty-nine percent of CC participants were satisfied with their jobs (greater than 4). Findings from mid-project interviews with the coaches revealed difficulty with scheduling appointments, significant efforts needed to get the "right" people at the table and need for the DCPR tools to be more userfriendly. No post-intervention results were collected due to closing of the CCs to visitors due to COVID. The DCPR tools shows promise and are being evaluated in additional CCs.

DEVELOPMENT OF AN ANIMAL-ASSISTED ACTIVITY/THERAPY DOG CHECKLIST FOR LONG-TERM CARE FACILITIES
Karen Dunn, 1 Amy Johnson, 1 and Melissa Winkle, 2 , 1. Oakland University,Rochester,Michigan,United States,2. American Occupational Therapy Organization,North Bethesda,Maryland,United States Animal-assisted activities (AAA) and therapy standards of practice have been published to protect the well-being of animals, animal handlers, and the special populations of patients that benefit from this mode of treatment. Inconsistencies among practice standards with concerns surrounding the topics of dog welfare, human well-being, and zoonotic transmission have been reported. The purpose of this qualitative research study was to review published AAA and therapy standards with older adult populations for best practices, conduct focus group sessions with caregivers from long-term care facilities that allow therapy dog visitation, and synthesize findings into an AAA checklist to be used by long-term care facility decision-makers when interviewing or bringing in therapy dog teams. Comparative analyses utilizing a systematic and sequential approach was used to analyze the data from the focus group sessions. Due to the COVID-19 pandemic, only two focus group sessions at one long-term care facility were conducted resulting in a total of 15 caregivers. Four themes emerged from the data: promotes positive mood, essential resident screenings, caregiver roles, and memory aides. Relevant themes and AAA and therapy standards and guidelines were then combined in the development of the AAA/Therapy Dog Checklist. Administrators may find having a user-friendly AAA/therapy dog checklist a useful tool that can be used when interviewing therapy dog teams to ensure future dog therapy experiences will be positive and safe. The safety and well-being of residents in long-term care facilities and animals are essential to promote positive health outcomes for both populations. Resident distress behavior, a prevalent challenge in long-term care, contributes to resident morbidity, staff burden, and turnover. We describe an education model developed in the Veterans Administration (VA) Community Living Centers (CLC) through a CONCERT (VA CLCs' Ongoing Center for Enhancing Resources & Training) quality improvement series. The Distress Behavior Conversation (DBC) uses a team meeting structure and process. Informed by unmet need and relational coordination theories, it guides the whole team, inclusive of interdisciplinary team members and front-line staff with resident contact, through a collaborative problem-solving action-planning discussion. DBC uses facilitated round-robins to identify potential resident behavior causes and individualized solutions. DBC supports the team in maintaining whole person and whole team mindsets, thus challenging the narrower medical model of discipline-specific clinical mindsets and staff level hierarchies. Over two years we have co-created and refined DBC through trainings and team debriefings with over 80 CLCs. Care teams reported "aha" moments during DBCs their thinking shifted ("we are now looking at the REAL why"; "we went from asking, how did he fall? to, why did he fall?; "tended to try to treat falls in a standardized way, [but] when you focus on a specific person you get to focus on HIS needs"; "personal information about the Veteran is the 5th vital sign!"). Teams additionally reported reduced strain and improved collaborative thinking ("I feel better about what I'm doing...more motivated to keep going!; "Now I see it is a team approach -don't have to do it by myself.").

LEARNING BEST PRACTICES FOR EDUCATING A CAREGIVING WORKFORCE
Sweta Tewary, 1 Yumna Indorewala, 2 Nicole Cook, 3 Naushira Pandya, 3 Sashah Damier, 4 and Assma Twahir, 3 ,1. Nova Southeastern University,Fort Lauderdale,Florida,United States,2. NSU,NSU,Florida,United States,3. NSU,Davie,Florida,United States,4. NSU,Davie,FL,Florida,United States It is well established that the health professional workforce is not adequately prepared to meet the demands of an aging older population. Caregivers are often the backbone supplemental workforce for seniors, providing daily care with assistance with activities of daily living, with little training. Part of the mission of the South Florida Geriatric Workforce Enhancement Program (SFGWEP) is to support and empower caregivers through community based training programs. Between January 1 2020 to January 31, 2021 SFGWEP provided education to more than 340 caregivers on topics related to opioid use, effective communication with individuals with dementia and other topics. Attendees responded to a short evaluation survey, which included three multiple-choice questions on if attending was a good use of their time, if they gained knowledge and if they plan to apply material, and two open-ended questions to identify opportunities for improvement in future trainings. Responses were overwhelmingly positive (>98% for multiple-choice questions.) There were also three open-ended questions that were analyzed using a modified thematic approach. The three questions covered what attendees learned, what they wanted to learn more about and suggestions for improvement. Analysis suggests that attendees plan to be more mindful about communication (e.g. improve eye contact, listen more) and that they want more information on neurocognitive disorders and resent research, including psychological changes due to disease and medication side effects. In terms of improvement, attendees said the program should allow more time for questions and should use more engaging materials (polls, posters, flyers and case studies).

MULTIPLE STREAMS ANALYSIS OF THE LONG-TERM CARE INSURANCE IN SOUTH KOREA: UNDERSTANDING POLICY CHANGES (2008 -2014) Mijin Jeong, University of Kansas, LAWRENCE, Kansas, United States
The Long-Term Care Insurance (LTCI) Act in South Korea was enacted in 2008 to improve the quality of life of older adults by promoting better health and to mitigate the burden of care on family members. In 2014, the Enforcement Decree for the LTCI Act was revised to broaden criteria for eligible recipients of LTCI-related services and care. This policy analysis seeks to explore the political circumstances under which the Act was formed and how social environmental factors had evolved to revise the LTCI Act using a multiple streams policy analysis framework. A combination of factors influenced the status of LTCI policy agenda, including shifts in aged demographic structure and increasing medical expenditures. From the Korean National Dementia Plan, a pilot project of dementia care was conducting to prove the efficiency of dementia care service. While the Korean Senior Citizens Association (KSCA) was less successful gaining press attention around dementia care, the presidential election and candidates' election pledges were key factors to suddenly open the opportunity to extend the recipients for dementia care. The process through which the LTCI Act was revised and expanded showed the importance of the political environment associated with the election. Based on the recognition of LTIC policy agenda and already testing the efficiency of dementia care services, the election leaded to revision of LTCI Act and it quickly diffused by the new administration. From the revision of LTCI, international policymakers and scholars should recognize how the political events might use the policy for older adutls. Personal care aides (PCAs), along with other direct care workers, provide the hands-on care, including help with activities of daily living for individuals receiving care in residential care communities (RCC) and adult day services centers (ADSC). Recruitment and retention of such workers is a challenge as low pay, inadequate training, unsatisfactory roles and lack of benefits contribute to turnover. Using data from the 2018 National Study of Long-Term Care Providers, the only nationally representative data about PCAs in RCCs and ADSCs, this study will assess differences in training hours, benefits, and work roles among PCAs in these settings. About 76% of RCCs and 66% of ADSCs employed aides. On average, PCAs received 32 hours and 51 hours of initial training in ADSCs and RCCs, respectively. Results from bivariate analyses (accounting for complex survey design), showed that benefits received by PCAs varied by sector. A higher percentage of PCAs in ADSCs than in RCCs received health insurance for employees (60% vs. 46%), and pension (51% vs. 40%). About 51% of ADSCs and 46% of RCCs reported that PCAs rarely or sometimes attended care plan meetings. Further, 11% of RCCs and 15% of ADSCs reported that aides rarely or sometimes worked with the same care recipient. This overview of PCA activities, training and benefits may provide insights into approaches to improve the retention of PCAs and subsequently the quality of care provided across sectors. Older adults in extreme poverty refer to "three-noes people": no working ability, no income source, and no children or legal supporters. They are eligible for a governmentfunded welfare system called "Five Guarantee system". The majority of residents in rural welfare institutes are male older adults in extreme poverty. Research demonstrates that resilience is a critical factor in shaping health. This study aims to examine the association between resilience and mental health for male older adults in extreme poverty, and its differences in young-old (60-69 years), old-old (70-79 years), and oldest-old groups (≥80 years). A cross-sectional study was conducted with 1,427 eligible subjects in rural long-term care facilities from Anhui province in China during 2019, with a response rate of 77.4%. Resilience was measured by the Chinese version of Connor-Davidson Resilience Scale, including three subscales of optimism, strength and tenacity. Mental health was assessed using General Health Questionnaire-12. A MANOVA test revealed a significant difference among age groups on three subscales of resilience [Pillai's Trace=.023, F (6,1486) =2.709, p=.013, ηp2=.012]. Tukey Post hoc indicated the oldest reported significantly lower levels of strength, optimism, and tenacity compared to the other two groups. A multiple logistic regression identified a significant negative association between resilience and mental disorder for the old-old (OR=0.95, 95%CI:0.93-0.97) and oldest-old (OR=0.93, 95%CI: 0.88-0.99) groups. Our findings identified th differences in the link between resilience and mental health within the three different age groups. Resilience-training programs to improve mental health would require targeting specific subscales of resilience for each group.

ROBOTIC-ASSISTED VIRTUAL CARE
Lillian Hung, University of British Columbia, Vancouver, British Columbia, Canada